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Catheter-associated Urinary Tract Infection(CAUTI) Toolkit

Activity C: ELC Prevention Collaboratives

Carolyn Gould, MD MSCR

Division of Healthcare Quality PromotionCenters for Disease Control and Prevention

Disclaimer: The findings and conclusions in this presentation are those of the authors and do not

necessarily represent the views of the Centers for Disease Control and Prevention.



Outline

• Background

– Impact

– HHS Prevention Targets

– Pathogenesis

– Epidemiology

• Prevention Strategies

– Core – Supplemental

• Measurement

– Process

– Outcome

• Tools for Implementation/Resources/References



Background: Impact of CAUTI

• Most common type of healthcare-associatedinfection –

> 30% of HAIs reported to NHSN – Estimated > 560,000 nosocomial UTIs annually

• Increased morbidity & mortality – Estimated 13,000 attributable deaths annually –

Leading cause of secondary BSI with ~10% mortality

• Excess length of stay –2-4 days

• Increased cost – $0.4-0.5 billion per year nationally

•

Unnecessary antimicrobial use

Hidron AI et al. ICHE 2008;29:996-1011 Givens CD, Wenzel RP. J Urol 1980;124:646-8

Klevens RM et al. Pub Health Rep 2007;122:160-6 Green MS et al. J Infect Dis 1982;145:667-72

Weinstein MP et al. Clin Infect Dis 1997;24:584-602 Foxman B. Am J Med 2002;113:5S-13S

Cope M et al. Clin Infect Dis 2009;48:1182-8

Saint S. Am J Infect Control 2000;28:68-75



Background: Urinary

Catheter Use

• 15-25% of hospitalized patients

• 5-10% (75,000-150,000) NH residents

• Often placed for inappropriate indications

• Physicians frequently unaware• In a recent survey of U.S. hospitals:

– > 50% did not monitor which patients catheterized

– 75% did not monitor duration and/or discontinuation

Weinstein JW et al. ICHE 1999;20:543-8 Munasinghe RL et al. ICHE 2001;22:647-9

Warren JW et al. Arch Intern Med 1989;149:1535-7 Saint S et al. Am J Med 2000;109:476-80

Benoit SR et al. J Am Geriatr Soc 2008;56:2039-44 Jain P et al. Arch Intern Med 1995;155:1425-9

Rogers MA et al J Am Geriatr Soc 2008;56:854-61 Saint S. et al. Clin Infect Dis 2008;46:243-50



Background:

HHS Metrics and Prevention Targets

•

# of symptomatic UTI / 1,000 urinary catheter days as measured in NHSN – National 5-Year Prevention Target: 25% decrease

from baseline

• Appendix G in HHS plan discusses a new typeof metric, the standardized infection ratio (SIR)

http://www.hhs.gov/ophs/initiatives/hai/prevtargets.html

http://www.hhs.gov/ophs/initiatives/hai/appendices.html



Background: Pathogenesis of

CAUTI

* Source ofmicroorganisms may beendogenous (meatal,rectal, or vaginalcolonization) or exogenous, usually viacontaminated hands ofhealthcare personnel

during catheter insertionor manipulation of thecollecting system

Figure from: Maki DG, Tambyah PA. Emerg Infect Dis 2001;7:1-6



Background: Pathogenesis of

CAUTI

• Formation of biofilms by

urinary pathogens

common on the surfacesof catheters and

collecting systems

•

Bacteria within biofilmsresistant to antimicrobials

and host defenses

•

Some novel strategies inCAUTI prevention have

targeted biofilms

Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp

Scanning electron micrograph of S. aureus bacteria

on the luminal surface of an indwelling catheter withinterwoven complex matrix of extracellular

polymeric substances known as a biofilm



CAUTI Definitions

• Surveillance definitions for UTI recently modified inNHSN (as of Jan 2009)

–

Please refer to NHSN Patient Safety Manualhttp://www.cdc.gov/nhsn/library.html

• Count symptomatic UTI (SUTI) only, not asymptomatic

bacteriuria (ASB) – Exception is “ABUTI” (asymptomatic bacteremic UTI) – seeNHSN manual above

• Clinical significance of ASB unclear

–

Should not screen for or treat ASB routinely, except in certainclinical situations

– Most literature to date includes ASB in outcomes, makinginterpretation of data difficult



Evidence-based Risk Factors

for CAUTI

Symptomatic UTI Bacteriuria

Prolonged catheterization* Disconnection of drainage system*

Female sex† Lower professional training of inserter *

Older age† Placement of catheter outside of OR†

Impaired immunity† Incontinence†

Diabetes

Meatal colonization

Renal dysfunction

Orthopaedic/neurology services

* Main modifiable risk factors † Also inform recommendations



Prevention Strategies

• Core Strategies

• Supplemental

– High levels ofStrategies

scientific evidence

– Some scientificevidence

– Demonstrated – Variable levels offeasibility feasibility

*The Collaborative should at a minimum include core prevention

strategies. Supplemental prevention strategies also may be used.Most core and supplemental strategies are based on HICPACguidelines. Strategies that are not included in HICPAC guidelines willbe noted by an asterisk (*) after the strategy. HICPAC guidelines may

be found at www.cdc.gov/hicpac



Core Prevention Strategies

(all Category IB)

• Insert catheters only for appropriate indications• Leave catheters in place only as long as needed• Ensure that only properly trained persons insert

and maintain catheters• Insert catheters using aseptic technique and

sterile equipment (acute care setting)• Following aseptic insertion, maintain a closed

drainage system

• Maintain unobstructed urine flow• Hand hygiene and Standard (or appropriate

isolation) Precautionshttp://www.cdc.gov/hicpac/cauti/001_cauti.html




Specific recommendations (IB)

• Insert catheters only for appropriate indications

http://www.cdc.gov/hicpac/cauti/001_cauti.html





• Insert catheters only for appropriate indications

– Minimize use in all patients, particularly those athigher risk of CAUTI and mortality (women, elderly,impaired immunity)

– Avoid use for management of incontinence – Use catheters in operative patients only as necessary






• Leave catheters in place only as long as needed

– Remove catheters ASAP postoperatively, preferablywithin 24 hours, unless there are appropriateindications for continued use






• Insert catheters using aseptic technique and

sterile equipment (acute care setting) – Perform hand hygiene before and after insertion

– Use sterile gloves, drape, sponges, antiseptic or

sterile solution for periurethral cleaning, single-usepacket of lubricant jelly

– Properly secure catheters








• Maintain unobstructed urine flow – Keep catheter and collecting tube free from kinking

– Keep collecting bag below level of bladder at all times(do not rest bag on floor)

– Empty collecting bag regularly using a separate,

clean container for each patient. Ensure drainagespigot does not contact nonsterile container.




Core Prevention Strategies:Specific recommendations (IB)

•

Implement quality improvement programsto enhance appropriate use of indwellingcatheters and reduce risk of CAUTI

Examples:

― Alerts or reminders

―Stop orders

―

Protocols for nurse-directed removal ofunnecessary catheters

―Guidelines/algorithms for appropriateperioperative catheter management




Supplemental Prevention

Strategies: Examples

• Consideration of alternatives to indwelling

urinary catheterization (II)• Use of portable ultrasound devices for assessing

urine volume to reduce unnecessary

catheterizations (II)• Use of antimicrobial/antiseptic-impregnatedcatheters (IB, after first implementing corerecommendations for use, insertion, andmaintenance ) http://www.cdc.gov/hicpac/cauti/001_cauti.html

• The following slides will provide further detailson supplemental strategies…



Supplemental Prevention Strategies:

Alternatives to Indwelling Catheterization

• Intermittent catheterization – consider for:

– Patients requiring chronic urinary drainage forneurogenic bladder • Spinal cord injury

• Children with myelomeningocele

– Postoperative patients with urinary retention

– May be used in combination with bladder ultrasound

scanners• External (i.e., condom) catheters – consider for:

– Cooperative male patients without obstruction or

urinary retention http://www.cdc.gov/hicpac/cauti/001_cauti.html




Bladder Ultrasound Scanners

• Rationale: fewer catheterizations = lower risk of UTI

•

2 studies of adults with neurogenic bladderundergoing intermittent catheterization

• Inpatient rehabilitation centers

•

Fewer catheterizations per day but no reporteddifferences in UTI

– Significant study limitations: likely underpowered;

UTIs undefined

Polliak T et al. Spinal Cord 2005;43:615-19

Anton HA et al. Arch Phys Med Rehab 1998;79:172-5




Antimicrobial/Antiseptic-Impregnated UrinaryCatheters

• Considered using if CAUTI rates notdecreasing after implementing acomprehensive strategy

– First implement core recommendations foruse, insertion, and maintenance

– Ensure compliance with corerecommendations





Silver-Coated Catheters

• Decreased risk of bacteriuria compared to standardlatex catheters in a meta-analysis of RCTs

• Significant differences for silver alloy but not silveroxide-coated catheters

•

Effect greater for patients catheterized < 1 week• Mixed results in observational studies in

hospitalized patients

–

Most used laboratory-based outcomes (bacteriuria)

– 1 positive, 2 negative, 5 inconclusive





Silver-Coated Catheters

• One study in a burn referral center found a

decrease in SUTI• Pre-intervention catheters standard latex

• Intervention group had silver-impregnated

catheters and had new catheters inserted onadmission under nonemergent sterile conditions

– “The improved results in time period 2 are probablydue to the combination of these two changes intherapy.”

Newton et al. Infect Control Hosp Epidemiol 2002;23:217-8



Summary of Prevention Measures*

Core Measures

• Insert catheters only forappropriate indications

• Leave catheters in place onlyas long as needed

• Only properly trained persons

insert and maintain catheters• Insert catheters using aseptic

technique and sterileequipment

•

Maintain a closed drainagesystem• Maintain unobstructed urine

flow• Hand hygiene and standard (or

appropriate isolation)precautions

Supplemental Measures

• Alternatives to indwellingurinary catheterization

• Portable ultrasound devicesto reduce unnecessarycatheterizations

•

Antimicrobial/antiseptic-impregnated catheters

*All recommendations in HICPAC guidelines at:




Strategies NOT recommended

for CAUTI prevention

• Complex urinary drainage systems (e.g., antiseptic-releasing cartridges in drain port)

•

Changing catheters or drainage bags at routine, fixedintervals (clinical indications include infection,obstruction, or compromise of closed system)

•

Routine antimicrobial prophylaxis• Cleaning of periurethral area with antiseptics while

catheter is in place (use routine hygiene)

•

Irrigation of bladder with antimicrobials• Instillation of antiseptic or antimicrobial solutions intodrainage bags

• Routine screening for asymptomatic bacteriuria (ASB) http://www.cdc.gov/hicpac/cauti/001_cauti.html



Measurement: Examples of

Process Measures

• Compliance with hand hygiene

• Compliance with educational program

• Compliance with documentation of

catheter insertion and removal• Compliance with documentation of

indications for catheter placement




Measurement: Recommended

Outcome Measures

• Examples of metrics: – Number of CAUTI per 1000 catheter-days

– Number of BSI secondary to CAUTI per 1000catheter-days

– Catheter utilization ratio (urinary catheter-

days/patient-days) x 100

• Use CDC/NHSN definitions for numerator data(SUTI only): http://www.cdc.gov/nhsn/library.html




Measurement: Outcome

Use NHSN Device-associated Module

http://www.cdc.gov/nhsn/library.html



Measurement Considerations

• May need to consider alternative metrics (in

addition to standard rates by device days) todemonstrate a reduction in CAUTIs if catheterdays (denominators) greatly reduced with

interventions• Alternative denominator examples:

– Patient days on unit

– Numbers of catheters inserted



Evaluation Considerations

•

Assess baseline policies and procedures

•

Areas to consider – Surveillance – Prevention strategies – Measurement

• Coordinator should track new

policies/practices implemented during

collaboration



References/resources

• Gould CV,UmscheidCA,AgarwalRK,KuntzG,PeguesDA,andHICPAC.GuidelineforPreventionof Catheter‐associatedUrinaryTractInfections

2009.http://www.cdc.gov/hicpac/cauti/001_cauti.html

IHIProgramtoPreventCAUTIhttp://www.ihi.org/

APIC

CAUTI

Elimination

Guide

http://www.apic.org/

IDSA

Guidelines

(Clin

Infect

Dis

2010;50:625‐63)

SHEA/IDSACompendium(ICHE2008;29:S41‐S50)

National

Quality

Forum

(NQF)

Safe

Practices

for

Better

Healthcare

–

Update

April

2010

CDC/Medscape

collaboration

http://www.cdc.gov/hicpac/

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